Patient Medical History & Medical Record Keeping: Accurate Problem Identification for Effective Solution

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Abdul Kader Mohiuddin
Department of Pharmacy, World University of Bangladesh

Obtaining an accurate medication history, keeping and proper maintenance of patient medical records, tracking medication lists are essential parts of medicine reconciliation and these are the processes where pharmacists play a vital role in. Without all these, prescribers may inadvertently make incorrect decisions about a patient’s treatment, causing harm if previously discontinued medicines are restarted, or if current medicines are omitted or prescribed at the wrong dose for the patient. Medical records are a fundamental part of a physician’s duties in providing patient care. Medical records can contain a wide range of material, such as handwritten notes, computerized records, correspondence between health professionals, lab reports, imaging records, photographs, video and other recordings and printouts from monitoring equipment. Poor record keeping is a major factor in litigation cases brought against healthcare professionals.

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Figure 1. Importance of Thorough Communication on Patient History (Cordant Health Solutions, 2015). According to the online medical website Monthly Prescribing Reference, a communication breakdown between a physician and two of her colleagues contributed to an eventual patient overdose, and resulted in a wrongful death lawsuit against all three providers and several pharmacies. The prescribing physician was eventually dropped from the wrongful death lawsuit, but the case has continued against both previous physicians based on their lack of communication regarding the insurance letters and the patient’s history of doctor shopping – highlighting the importance of complete communication and comprehensive, timely transfer of patient information prior to further prescriptions or other treatments.

Medication histories have traditionally been documented in the ‘Drug history’ section of a physicians’ associates; if pharmacists or nurses identified any errors with this list, they would usually document these in the subsequent progress notes. Erroneous drug histories can lead to discontinuity of therapy, recommencement of ceased medicines, inappropriate therapy and failure to detect a drug-related problem. These errors can have adverse consequences for the patient during their hospital stay. Perpetuation of these errors on discharge may result in adverse events, from duplication of therapy, drug interactions and discontinuation of an essential medicine. Once an accurate medication history has been obtained, this information should be documented in the patient’s medical notes.

Accurate Medication History
Obtaining an accurate medication history is the first step of the medicine reconciliation process. Such histories usually consist of a list of all medicines (prescribed and purchased) that a patient was taking prior to their admission to hospital. Due to the lacking standardization of the medication lists, important information is frequently lacking or—in case of handwritten medication lists—not readable (Taib, 2010; Hartel, 2011). In addition to this, details of allergies or sensitivities to medicines (or excipients), recently stopped medicines (e.g. in the past month), and recent short courses of antimicrobials or corticosteroids should also be included (Harig, 2018).  Obtaining an accurate medication history in a pre-operative clinic will allow appropriate suspension of certain medicines (e.g. anticoagulants and antiplatelets) prior to surgery, preventing complications following surgery or the procedure being cancelled (if this information is identified on the day of surgery). There are also many records that are indirectly related to patient management such as accounts records, service records of the staff, and administrative records, which are also useful as evidences for litigation purposes (Nickless, 2016). Medical recording needs the concerted effort of a number of people involved in patient care (Kadam, 2017; WHO, 2006; Al-Bassam, 2016).  Documenting the medical history can be lifesaving as well. An encounter with an awake patient who is able to answer all questions which are subsequently recorded on the electronic medical record, could prove to have vital information in the event the patient mental status changes, or during a later encounter if the patient is unable to give their history such as in a traumatic accident (Nichol, 2019). Critically ill adults often have extended hospital lengths of stay and are at high risk of having medication-related adverse events. Between 70% and 95% of clinical records include inaccurate medication lists, and approximately 20% to 30% of all ambulatory patients experience an ADE annually (Bolster, 2019). Potential drug interactions and treatment duplications may result from prescribers being unaware of patients' complete list of home medications (Nester, 2002).

Sources of Medication/Patient History
Patient history simply reveals an idea of his profile, medication behavior, lifestyle, previous history of major/minor surgery, drug hypersensitivity, food habits etc. More often source of history is patient himself. A patient’s social history can provide useful information when reviewing their pharmaceutical care (Macchia, 2015; Regitz-Zagrosek, 2012; Worm, 2015; Shim, 2014). For example, smoking tobacco induces enzymes that speed up the metabolism of theophylline and changes in vitamin K consumption can reduce the efficacy of warfarin. Asking about a patient’s social history also facilitates asking questions about any recreational drug use such as cannabis or ecstasy.

Patients should always be consulted unless it is not physically possible (e.g. they are unconscious or confused). The WHO program Patients for Patient Safety also emphasizes the central role patients should play in efforts to improve the quality and safety of health care (McTier, 2015). A patient’s symptoms and measurements, along with the implications, factors at stake, and potential trade-offs of different management options, are likely to be discussed with family, friends, and peers (Vassilev, 2014). Direct discussion with the patient may also highlight issues with medicines adherence and identify other medicines that the patient uses (e.g. over the counter medicines, herbal medicines or medicines from specialist clinics) (Fitzgerald, 2009). Patients should also be consulted to confirm any previous allergies or intolerances to medicines. Patient participation in medication management during hospitalization has been proposed as a defense against medication errors and as a means of improving patients' adherence to medications once discharged from hospital (Michaelsen, 2015).

Parents and Associates: The validity of parental report was 81% for medication name, 79% for route of delivery, 66% for the form of the medication, and 60% for dose. Parents' report improved on the validity of documentation by physicians across all medication details save for medication name. Parents' report was more valid than nursing documentation at triage for all medication details (Rappaport, 2017).

Previous Surgery Reports provide medicine lists and information on medicines the GP has prescribed for the patient. Another consideration when obtaining information from GPs is the surgery opening hours. Although an increasing number of hospitals have access to patients’ summary care records (SCRs). In Scotland, the SCR contains elements such a patient’s name, address, age, allergies, current medications, diagnoses. It is connected to 100% of general practices, and is automatically updated from existing GP records. Its main objective is to be accessed in emergency and unscheduled care scenarios (Séroussi, 2016). When contacting hospital/GP receptionists, practitioners should remember that these individuals often receive little or no training regarding medicines and it may be more appropriate to obtain a written copy of the medication summary, usually in the form of a fax (Hewitt, 2009).

Previous discharge prescriptions (either filed in the case notes or accessed electronically) may help if a patient has been discharged from hospital recently (i.e. in the past month). However, it must always be confirmed whether there have been any changes to their medications since the previous discharge from hospital. Previous prescription of β-blockers may confer a survival advantage to patients who subsequently develop sepsis with organ dysfunction and who are admitted to an ICU (Macchia, 2012).

Medicine Administration Record (MAR) sheets will often accompany a patient admitted from a nursing or residential home. These should be read carefully to identify any medicines recently started, discontinued, refused or omitted. Extra care should be taken when reviewing MAR sheets with handwritten additions or amendments and those that do not indicate how many pages make up the MAR. Use of the eMAR application significantly reduces the rate of ME-MAR and their potential risk. The main cause of ME-MAR was the failure to follow work procedures (Vicente Oliveros, 2017). Electronic medical administration record (eMAR) systems offer an alternative strategy to study adherence to prescriptions in health care institutions and facilitate efficient review of a large number of drug administration events with no potential for observer effect bias (Dalton, 2015). Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors (Porter, 2005).

Patient medication lists (either repeat prescriptions or self-produced lists) may be brought directly with the patients on admission to hospital. The patient should be asked if this information is up-to-date and whether all parts of the repeat prescription list have been brought in. In Germany, 25–50% of patients with long-term medication have a medication list. An updated and comprehensive medication list may reduce patients' concerns and increase the perceived necessity of their medication. There should be a standard to prepare and providing medication list, otherwise it lacks important information. More often handwritten prescriptions are not completely readable (Jäger, 2015). It is possible that, if patients consulted other physicians or pharmacists for reasons, they think bear no relation to their current visit, they might not report additional drugs without being prompted. For example, a patient might be taking an anti-inflammatory medication for a musculoskeletal disorder but might not think to mention it to a doctor being consulted about hypertension. It is essential to ask patients explicitly whether new medications should be added to the list and to specify the reason for and dosage of the new medications (Lussier, 2007). Patient involvement is essential to maintain accurate and updated medication lists, provide quality care, and decrease potential errors (Chae, 2009).

Community pharmacies are regularly used, with studies reporting that in some regions more than 80% of patients use the same pharmacy for their regular medicines. However, since a patient may visit any community pharmacy, they may not hold an accurate list of all medicines and should not be used as a single source of information. The community pharmacy may provide information on compliance aids or medicines that are not supplied on a repeat prescription from the GP, such as methadone or medicines obtained from a memory clinic. Community pharmacies may also be able to give information when other sources are unavailable (e.g. methadone doses when the community drug service is closed) (Nickless, 2016).

Specialist clinics may also hold additional medicines information, so GPs may not have information about medicines that they do not prescribe. The patient’s medical history may suggest that they receive medicines via another prescriber (e.g. donepezil from a memory clinic, antiretrovirals from an HIV clinic, or methadone from a community drug service) (Nickless, 2016).

Care transition & Medication Errors (MEs)
Transition of care on admission to the hospital and between clinical areas are risk points for medication errors. All type of medication errors can be reduced by improving communication at each transition point of care. Medication histories are often recorded inaccurately by physicians at the time of hospital admission (Mazhar, 2018). Even one third of prescribing errors that occur in hospitals are a consequence of an incorrect medication history taken at the time of admission (Boostani, 2019; Petrov, 2018). Studies have shown that for 50 to 70% of admitted patients, the initial medication history contains at least one error (Schepel, 2019). In a recent similar study, a nearly 90% of the patients experienced at least one ME during their hospital stay which is lower than reported MEs rates by other studies in patients admitted to internal wards (Boostani, 2019; Petrov, 2018). Approximately half of all hospital medication errors and one third of ADEs occur as a result of miscommunication at interfaces of care (Petrov, 2018; Almanasreh, 2016). In addition, almost 60% of MEs occur at admission, transfer, or discharge from the hospital (Abu Farha, 2018). The average ME rate was 1.5 errors per patient at admission and 1.3 at discharge. Medication-related problems (MRPs) are common among home care patients who take many medications and have complex medical histories and health problems. In the case of older adults, ADRs contribute to already existing geriatric problems such as falls, urinary incontinence, constipation, and weight loss (Mohiuddin, 2019). However, the most common MEs were omissions, wrong dose and frequency, and inappropriate added medications. More than 35% of patients experienced serious or very serious MEs and almost 40% potentially moderate MEs (Breuker, 2017). ADEs are a major cause of morbidity and mortality, with more than 50% of ADEs being preventable (Naicker, 2018). A thorough and accurate admission medical record is an important tool in ensuring patient safety during the hospital stay (Amirian, 2014). Inaccurate medication history at admission to hospitals leads to preventable ADEs, which in turn increase mortality, morbidity, and health care costs (McShane, 2018).

Medication Discrepancies
Medication discrepancies are unintended differences between a patient's outpatient and inpatient medication regimens. The rate of discrepancy of medications is estimated to be between 38% and 50% for newly hospitalized patients (Abuyassin, 2011). Penm, 2019 reported that medication discrepancies occur in up to 80% of hospitalized patients during transitions of care, either at admission or discharge. They affect up to 60% of patients admitted to hospital (Stockton, 2017). Older patients are especially at risk, as polypharmacy, comorbidities, and longer hospital stays are associated with increased MEs. Furthermore, it has been shown that incomplete medication lists at admission can result in medication errors at discharge (Graabæk, 2019). Insight into potential risk factors associated with these discrepancies would be helpful to focus the second medication reconciliation on high-risk patients (Ebbens, 2018). Patient history data from electronic medical record (EMR) may not accurately represent a patient’s full prescription drug profile. An infrastructure to provide medication history services appears essential (Frisse, 2010). In the patient’s eyes, the ability to communicate well forms a major component of a provider’s clinical competence. The ability to communicate effectively with patients can contribute significantly to improved patient outcomes (Berman, 2016).

Keeping Medical Records
A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care (Dang, 2014). The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient (Toney-Butler, 2019). Some studies conducted in the United States, India, and Brazil also reported that history-taking was responsible for nearly 80% of all diagnoses made and that investigations played complementary roles in excluding other diagnostic options and increased physicians’ self-confidence (Benseñor, 2004; Roshan, 2000; Peterson, 1992). Additionally, a less equipped primary health care center may still arrive at a correct diagnosis in about 88% of cases following brief history-taking and physical examination, and treatment can be commenced based on these findings (Oyedokun, 2016). Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. Consequently, clinical records should be updated, where appropriate, by all members of the multidisciplinary team that are involved in a patient’s care (physicians, surgeons, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, chaplains, administrators or students) (Mathioudakis, 2016).



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